What do you guys hate about psychiatry?

[NontradCA]

I have to agree with this, it's far too simplistic to condense something as multi-faceted as mental illness down to just one nice, neat, identifiable reason for it's existence. Even with something like psychosis I don't believe its that cut and dried that it is something going on in the brain with no other factors to consider. In my case, for example, yes there is most likely a brain element to the psychotic features part of being diagnosed with MDD with Psychotic fx, considering I have a family history of Schizophrenia and other Psychosis type spectrum disorders, but then you also have to factor in other elements such as repeated exposure to trauma as a child, underlying psychological make up, and so on. Just personally I've found myself doing far better in terms of symptom control during an episode after receiving ongoing psychotherapy with medication as an adjunct only when truly needed, rather than just being told 'well you have psychotic symptoms, that means there's something wrong with the way your brain works, take these meds and you'll be fine'.

I honestly have never heard any medical provider describe the complete pathophys of any mental illness, or a lot of other illnesses for that matter. Well, maybe a psychoanalyst .

I'm not sure why it has to be black and white with these issues. "We're never going to full figure out behavior, let's stop trying" is stupid, IMO. Maybe I'm not cut out for Psych, but Im not sure what's wrong with wanting better treatments while simultaneously giving the best available and you know, practicing medicine.

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[Ceke2002]

I honestly have never heard any medical provider describe the complete pathophys of any mental illness, or a lot of other illnesses for that matter. Well, maybe a psychoanalyst .

I'm not sure why it has to be black and white with these issues. "We're never going to full figure out behavior, let's stop trying" is stupid, IMO. Maybe I'm not cut out for Psych, but Im not sure what's wrong with wanting better treatments while simultaneously giving the best available and you know, practicing medicine.

I don't disagree, my point was more aimed towards having tunnel vision whereby in the pursuit of better treatments you become so focused on just one aspect that you disregard anything else.

 

[Shikima]

What do I hate? Court.

 

[NontradCA]

I don't disagree, my point was more aimed towards having tunnel vision whereby in the pursuit of better treatments you become so focused on just one aspect that you disregard anything else.

Fair enough.

 

[psyche108]

A little late, but thanks for all of your replies everyone! I actually have some more questions in regards to this.

Is there anything about interacting with the patients that you hate? One criticism I tend to hear a lot about primary care patients is that so many of them are lazy in regards to their own health and would rather find a pill to help cure everything, instead of following nutritional or exercise recommendations. Is it the same thing with psychiatry? Meaning that there are some problems that can be solved with psychotherapy alone, but some patients are unwilling to put in the effort? Are there certain personalities in psychiatry that you run into a lot or are their certain behaviors in psych patients that make you feel less empathetic and more frustrated or impatient?

I'm assuming that most psychiatrists are guaranteed to see these patients sometime in their career, but how common is it for psychiatrists to dislike/hate their patients? Are there certain settings where you deal with certain types of patients such as inpatient, outpatient, private practice, med management, psychotherapy, etc?

 

[wolfvgang22]

Ummm....it's psychiatry. We work with people with mental health issues. If anything, we see more patients with personality disorders or traits thereof, which can be quite disagreeable and frustrating. Cluster B personality disorders are often challenging. And we see such people nearly every day.
Most patients do want a pill to cure all, with no hard work such as participating in psychotherapy. So, same deal as all of medicine. At the same time, we are expected to have much more patience with such individuals, because we are psychiatrists. I think that makes psychiatry more difficult.
For me, no, I don't really hate any patients. Sometimes I dread seeing certain people, and its frustrating many times, but I always hope for the best.

 

[thepoopologist]

A little late, but thanks for all of your replies everyone! I actually have some more questions in regards to this.

Is there anything about interacting with the patients that you hate? One criticism I tend to hear a lot about primary care patients is that so many of them are lazy in regards to their own health and would rather find a pill to help cure everything, instead of following nutritional or exercise recommendations. Is it the same thing with psychiatry? Meaning that there are some problems that can be solved with psychotherapy alone, but some patients are unwilling to put in the effort? Are there certain personalities in psychiatry that you run into a lot or are their certain behaviors in psych patients that make you feel less empathetic and more frustrated or impatient?

I'm assuming that most psychiatrists are guaranteed to see these patients sometime in their career, but how common is it for psychiatrists to dislike/hate their patients? Are there certain settings where you deal with certain types of patients such as inpatient, outpatient, private practice, med management, psychotherapy, etc?

There are patients like that in every specialty. Some can really turn themselves around. Some cannot. What doesn't help is hating them and wanting them to go away instead of using your brain and figuring out what's wrong and how to address the issue. When you feel that strong of an emotion toward a patient, you will miss something, and what you miss may or may not be the piece that makes a difference.

 

[smalltownpsych]

We get lots of patients who don't have sufficient motivation to change their behaviors and are looking for the quick fix. Heck, I don't really want to change some of my behaviors and would like a quick fix, too. A good psychologist or psychiatrist will look in the mirror themselves and see the shared humanity before hating on patients. Doesn't mean I don't get frustrated, but I recognize that my emotional state is mine and blaming others is not too productive. I learned that from listening to patients who do that all day long and don't improve because they can't take responsibility for their own emotional well-being so I try not to do the sames thing too much. 🙂

 

[Jeffrety]

I have a difficult time dealing with PDs especially BPD. Everything is a struggle when dealing with them. They wont take their meds (which dont help anyway but thats a different story), they refuse to stick to treatment plans, they like canceling and/or constantly rescheduling because it is an easy way for them to spite you or play power games against you. And you never know what antics they will pull off next. One visit BPD patients seem happy and tell you they doing much better and seeing their therapist and how awesome their personal life is. Then next time they are distraught and near suicidal with fresh cut marks on their forearms because their therapist was "judgemental" and their partner made an slightly off-hand comment that the patient has taken to heart and now they cannot stand that person but at the same time the still want to be with them. This erratic, love-hate roller coaster personality with wild mood swings and blatant cries for attention describes 90% of the BPD patients I saw in OP psych.

 

[psyche108]

Bumping this thread again, but I was wondering based on some of the other threads here if there's anything about the clinical practice of psychiatry you hate. The initial replies on this thread talk about things like dealing with insurance companies or things that apply to medicine in general or bad colleagues, but is there anything you guys hate specifically about the actual clinical practice of psychiatry or psychiatric patients? Are there certain settings where you guys feel more frustrated than others? Are there certain patients that make you feel more frustrated and how often and in what settings do you get those patients?

I'm currently debating whether I want to actually do something in healthcare at all or if I should do something totally different and stick with my original non-healthcare career goals.

 

[Leo Aquarius]

Step 1. Be a doctor vs something else major life decision -> Step 2. Can I get into med school -> Step 3. Can I survive med school and pass my exams -> Step 4. Can I pass my boards -> Step 5. Surgery vs non-surgery career -> Step 6. Flirt with a dozen specialties -> Step 7. I finally decided on X -> Step 8. Oops, changed my mind for Y -> Step 9. Ooops, changed my mind again for Z -> Step 10. I think I'm going with psychiatry as my Z, but wait, what do I really like or fear about psychiatry?

What is a youngin like you doing trying to jump to Step 10 when you haven't even passed Step 1?

 

[priu]

-controlled substances
-addiction problems
-lack of insight and motivation to improve
-benzodiazepines - yes quick, effective, but associated with motor vehicle accidents and long term cognitive impairment
-patients looking for the pill fix and unwilling to take the steps necessary for better health (physical + mental)


-pressure from the productivity model. Let me explain this one. More patients = more pay. You can bill for higher level codes (complex interactive, therapy), but the documentation is stricter and you need to have knowledge and specifics to do it. Even with the higher level codes, you will make more money under a productivity model by seeing more patients and spending less time with them.

To get credit for a medication management and psychotherapy, you document total time and time for psychotherapy. The interview is fluid and dynamic. Should I be telling patients from 10:13 am to 10:33 AM is purely therapy and then from 10:33 to 11:00 is purely medication? Sorry, it's not time yet for the psychotherapy portion of your visit.

There are no direct financial incentives for providing high quality of care. People will get dinged for providing poor care, but no financial repercussions. Sure, I can go with the productivity model- know my patients less, fail to explain the benefits of psychotherapy, not have the time to understand potential diagnoses, miss key details such as compliance and the reasons for it, fail to diagnose underlying disorders, unable to provide psychotherapeutic interventions.

I am more effective as a Psychiatrist when I get time with my patients. I suppose I could switch to more patients per hour, but will need to rely more on benzodiazepines and the odd balance of benefits and reactions for treatment resistant patients, antipsychotics that can potentially contribute or cause diabetes, and sedative hypnotics for which patients will not care to address sleep issues.

 

[sunlioness]

You know, I used to rail about RVUs. When I was looking for jobs having a straight salary was one of the must have criteria. And now I miss RVUs. At my old place I had much more control over my schedule. Yes, I was directly affected by no shows. But I had more control over my schedule, how long my appointments were, and how many I scheduled. Sure, I could make more money if I stacked people. But that was ultimately my choice.

Now? I make a straight salary. I am not directly affected by no shows. But my employer is. I have no control over my schedule. They stack it to minimize the effect of no shows. If I have thirty people scheduled in a day and all thirty show up, I don't benefit from that. I miss my RVUs.

At my old job the most patients I cold have scheduled in a day was 16. I also had it set so I didn't do more than two new patient evals per day. At my current job my max patients per day is 32. And there is no limit on how many evals are put on my schedule. I have no control over that whatsoever. I made significantly more at the last place, but I think region is also playing into that quite a bit.

I'm not faulting my current employer or my former employer. They both simply chose different strategies to survive in the same flawed system. A system that isn't set up to benefit patients or doctors.


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[nancysinatra]

So I'm late to this thread and haven't read the whole thing, but I did appreciate Splik's list of grievances, and I agree with them all. Off the top of my head, some gripes I have are:

- Seeing so many Americans misuse the disability system
- Dealing with patient with chronic pain and/or substance abuse but who aren't motivated to change
- Having to be nice to people all day, including a lot of people who are being totally unreasonable
- Having to tell strangers what I do
- Dealing with other people in the field who have as much pathology as the patients. This is especially bad in academia.
- Not having definitive cures for any illnesses the way they do in surgery or infectious disease
- Being told how effective atypicals and SSRIs are when I have almost never seen a patient completely cured by them
- Patients who won't stop talking
- Patients who won't answer questions
- Hearing about insomnia and/or restless legs
- The PHQ-9
- Endless documentation
- Having to adapt my practice style to the local environment which is absolutely dominated by nurse practitioners
- The corrupt, coercive mental health commitment system in my current state
- The fact that so many psychiatrists forget everything about medicine, or weren't very good at it to begin with

 

[OldPsychDoc]

So I'm late to this thread and haven't read the whole thing, but I did appreciate Splik's list of grievances, and I agree with them all. Off the top of my head, some gripes I have are:

- Seeing so many Americans misuse the disability system
- Dealing with patient with chronic pain and/or substance abuse but who aren't motivated to change
- Having to be nice to people all day, including a lot of people who are being totally unreasonable
- Having to tell strangers what I do
- Dealing with other people in the field who have as much pathology as the patients. This is especially bad in academia.
- Not having definitive cures for any illnesses the way they do in surgery or infectious disease
- Being told how effective atypicals and SSRIs are when I have almost never seen a patient completely cured by them
- Patients who won't stop talking
- Patients who won't answer questions
- Hearing about insomnia and/or restless legs
- The PHQ-9
- Endless documentation
- Having to adapt my practice style to the local environment which is absolutely dominated by nurse practitioners
- The corrupt, coercive mental health commitment system in my current state
- The fact that so many psychiatrists forget everything about medicine, or weren't very good at it to begin with

Happy Festivus!

 

[nancysinatra]

Happy Festivus!

Ahh thanks! One of the things I like about psychiatry: posts from OPD!

 

[nancysinatra]

Another thing I like about my job: that minute, on December 23rd, when the last patient of the day misses the cut off for making his appointment in time! Happy Holidays everyone!

 

[F0nzie]

Another thing I like about my job: that minute, on December 23rd, when the last patient of the day misses the cut off for making his appointment in time! Happy Holidays everyone!

Or in my case a fight breaking out in the lobby. Merry Christmas everyone!

 

[Messerschmitts]

As a County psychiatrist I wouldn't say I hate, but I am frustrated by not being able to refer patients to things that will actually help them. For example:

1.) Borderline Personality disorder: They need DBT, but County doesn't have it, they offer the patients once a month 30 min supportive therapy and expect me to fix it with meds.
2.) Gambling addiction: no resources
3.) Eating disorders: very few resources
4.) Sex offenders/paedophilia: I'm supposed to do what with these patients? Nowhere to send them.

Also, disability fights.

 

[sunlioness]

Yeah. I'm not quite sure what to do with sex offenders either. Because they get sent there and I have to diagnose them with something so they can get treatment. Which leads to frustrating conversations when there isn't a diagnosis. He's just an dingus who rufied his friend who needs a good consciousness raising and some jail time. "But you have to diagnose him with something. " "Why?" "So he can get treatment." "For what?" "For being a sex offender."

Edited: Dingus? Ha! I like this forum censor.

 

[OldPsychDoc]

Or in my case a fight breaking out in the lobby. Merry Christmas everyone!

Ahh thanks! One of the things I like about psychiatry: posts from OPD!

Then let me interrupt the airing of grievances with a touch of positivity, and recycle this oldie-but-goodie..

Working Christmas again this year, still love my team. (and BTW, that same local parish came again last night--carolled every psych floor and brought a gift for each patient, as well as small gifts for the patients' children!)

 

[birchswing]

Or in my case a fight breaking out in the lobby. Merry Christmas everyone!

I would like to see this honestly.

I swear I feel like I'm the only mentally ill person I've ever seen in a psychiatrist's waiting room. I have trouble sitting still, I make vocal tics, sometimes I walk outside to get fresh air, I am fidgeting, I wear sunglasses indoors, I always hear a hat, I get anxious about feeling my BP creep up so I take out my BP monitor and measure it, I'm taking my hat on and off revealing my flop sweat hair. I basically look nuts.

I've never been to a therapist or psychiatrist's waiting room where everyone else doesn't look totally at peace and like they're waiting to get their hair done.

I don't see anyone that looks mentally ill at all. And I know the whole invisible disability thing, but you'd think I would have run into someone talking to themselves or having some sort of fit, etc.--but never have.

 

[sunlioness]

Last week a patient in the waiting room was spitting on people.


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[birchswing]

Last week a patient in the waiting room was spitting on people.


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That never happens around here. Never seen it. Sometimes I wonder what all these people have who are seeing psychiatrists because they seem so incredibly normal (again, I know mental illness often has no outward symptoms--but I'm talking about never seeing outward symptoms).

This was the same problem I had in high school. I had vocal tics that I was so embarrassed of and I tried to suppress them. I was in classes with 50 minute lectures and world beater students who sat in rapt silence. You could hear a pin drop --and you could certainly hear me, which is why I would often leave class when I couldn't hold in the louder grunting sounds.

One night my school had a free SAT prep course. The general population students attended mostly. So much noise and kids goofing off that I felt perfectly comfortable. There was always enough white noise that no one noticed. I do better when I'm around people misbehaving enough that I feel like I can get lost in the crowd.

 

[keifernny2]

Yeah. I'm not quite sure what to do with sex offenders either. Because they get sent there and I have to diagnose them with something so they can get treatment. Which leads to frustrating conversations when there isn't a diagnosis. He's just an dingus who rufied his friend who needs a good consciousness raising and some jail time. "But you have to diagnose him with something. " "Why?" "So he can get treatment." "For what?" "For being a sex offender."

Edited: Dingus? Ha! I like this forum censor.

Antisocial personality disorder? Narcissistic personality disorder?



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[sunlioness]

It begs the question though . . . Is a guy who rufied his friend and had sex with her going to benefit from group therapy to hash it out so he doesn't do it anymore? He knew it was wrong when he did it. He did it anyway because he wanted to. He's only here getting treatment because some judge told him he has to and it beats sitting in a jail cell. He's not motivated to change. He's not mentally ill. He is, to quote the forum censor, a dingus. But some judge somewhere has ordered sex offender treatment and therefore I have to give this guy a mental illness label so it can all get paid for. It's nuts.


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[smalltownpsych]

It begs the question though . . . Is a guy who rufied his friend and had sex with her going to benefit from group therapy to hash it out so he doesn't do it anymore? He knew it was wrong when he did it. He did it anyway because he wanted to. He's only here getting treatment because some judge told him he has to and it beats sitting in a jail cell. He's not motivated to change. He's not mentally ill. He is, to quote the forum censor, a dingus. But some judge somewhere has ordered sex offender treatment and therefore I have to give this guy a mental illness label so it can all get paid for. It's nuts.


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Why do you have to treat him? I do not treat sex offenders because I am not qualified in any way to provide that treatment. Aren't there sex offender programs that he would have to pay for himself? It is like the patients that try to come see me for court-ordered anger management. I don't do that either and they are only trying to get their insurance to pay for it because the real program wants cash up front. No way am I going to play that game.

 

[sunlioness]

I do what I'm told. I have no training in it either, but apparently we do have a program. But everyone needs to see a psychiatrist first at time of intake and then at least every three months thereafter whether they're on meds or not. And apparently I have to diagnose them with something. I don't do the actual treatment. I'm not even sure what it entails. Group of some sort.


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[smalltownpsych]

I do what I'm told. I have no training in it either, but apparently we do have a program. But everyone needs to see a psychiatrist first at time of intake and then at least every three months thereafter whether they're on meds or not. And apparently I have to diagnose them with something. I don't do the actual treatment. I'm not even sure what it entails. Group of some sort.


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Ugh. Sorry you have to see these people. So basically your job is to rule out other mental illness. ICD 10 code for sex abuser is Y07 and the code for unspecified mental illness would be F99
When i saw sex offenders from time to time at a county jail they wanted treatment for their depression and anxiety about being in jail. I would tell them that jail is a scary and depressing place so i can't really help you much with that.

 

[sunlioness]

Thank you. That's helpful. They told me to use unspecified sexual dysfunction, but that didn't seem quite right ...


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[Messerschmitts]

I do what I'm told. I have no training in it either, but apparently we do have a program. But everyone needs to see a psychiatrist first at time of intake and then at least every three months thereafter whether they're on meds or not. And apparently I have to diagnose them with something. I don't do the actual treatment. I'm not even sure what it entails. Group of some sort.


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I have similar issues. I think this happens when you work for a large entity. Once in awhile, I'll get a case where I am told, "you have to see this patient and do an H&P intake, they need a psychiatrist evaluation before we can transfer them to [xyz agency]". I ask, "okay why do I need to see this person? What exactly am I supposed to do?" "Just write an evaluation". "Uh...okay..." It would take more effort to figure out why I'm being asked to do this than to just see the pt and write an H&P.

 

[sunlioness]

Yep. That's it exactly. There was one I did for some sort of housing thing.


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[Messerschmitts]

Why do you have to treat him? I do not treat sex offenders because I am not qualified in any way to provide that treatment. Aren't there sex offender programs that he would have to pay for himself? It is like the patients that try to come see me for court-ordered anger management. I don't do that either and they are only trying to get their insurance to pay for it because the real program wants cash up front. No way am I going to play that game.

I'm not trained at all to treat paedophilia or sex offenders. I'm not sure how much talk therapy is going to help, and in terms of medication, what am I supposed to do? Chemical castration? I'm not trained in that either. However, every few months I get a patient who is here because they conducted lewd acts with a minor or something, and they show up "because the judge told me I needed to get help". "Don't you have a court-ordered programme you're supposed to go to?" "I dunno...can you just help me?"

 

[Messerschmitts]

Yep. That's it exactly. There was one I did for some sort of housing thing.


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Ha ha it's called the path of least resistance. Taoist psychiatry. Actually I guess in psychodynamic therapy you're supposed to take the path of maximum resistance LOL. But we're not doing Analysis here.

 

[Achillees]

You know, I used to rail about RVUs. When I was looking for jobs having a straight salary was one of the must have criteria. And now I miss RVUs. At my old place I had much more control over my schedule. Yes, I was directly affected by no shows. But I had more control over my schedule, how long my appointments were, and how many I scheduled. Sure, I could make more money if I stacked people. But that was ultimately my choice.

Now? I make a straight salary. I am not directly affected by no shows. But my employer is. I have no control over my schedule. They stack it to minimize the effect of no shows. If I have thirty people scheduled in a day and all thirty show up, I don't benefit from that. I miss my RVUs.

At my old job the most patients I cold have scheduled in a day was 16. I also had it set so I didn't do more than two new patient evals per day. At my current job my max patients per day is 32. And there is no limit on how many evals are put on my schedule. I have no control over that whatsoever. I made significantly more at the last place, but I think region is also playing into that quite a bit.

I'm not faulting my current employer or my former employer. They both simply chose different strategies to survive in the same flawed system. A system that isn't set up to benefit patients or doctors.


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So why did you leave?

 

[Achillees]

So I'm late to this thread and haven't read the whole thing, but I did appreciate Splik's list of grievances, and I agree with them all. Off the top of my head, some gripes I have are:

- Seeing so many Americans misuse the disability system
- Dealing with patient with chronic pain and/or substance abuse but who aren't motivated to change
- Having to be nice to people all day, including a lot of people who are being totally unreasonable
- Having to tell strangers what I do
- Dealing with other people in the field who have as much pathology as the patients. This is especially bad in academia.
- Not having definitive cures for any illnesses the way they do in surgery or infectious disease
- Being told how effective atypicals and SSRIs are when I have almost never seen a patient completely cured by them
- Patients who won't stop talking
- Patients who won't answer questions
- Hearing about insomnia and/or restless legs
- The PHQ-9
- Endless documentation
- Having to adapt my practice style to the local environment which is absolutely dominated by nurse practitioners
- The corrupt, coercive mental health commitment system in my current state
- The fact that so many psychiatrists forget everything about medicine, or weren't very good at it to begin with

I'm curious as to why this is a point of contention with you regarding psych. I mean, there's a reason psych's psych and medicine is medicine, especially if you yourself chose psychiatry. I'm only a medical student, but reading your list implies you chose your specialty poorly.
Also, this is the first time i'm hearing about NP domination. Care to elaborate?

 

[Shikima]

So why did you leave?

It takes a while to figure it all out. For the past 10-15 years, physicians are heavily institutionalized. Going to PP or an RVU model has a period of adjustment and depending on the person's likes and personality dynamics, and how the practice environment operates is all influential.

 

[sunlioness]

Yes. Like I explained in my post. I railed against that system when I was in it and specifically looked for a job where they didn't do it that way. Only to realize that it's way worse. I also thought I wanted to move back to where I grew up. But that was also kinda dumb because I don't really know too many people here anymore and the cost of living is high.

Giving serious thought to reaching out to the old boss to see if he wants me back. The grass isn't greener. And living at home doesn't count for much when you're too stressed out to take advantage of it and don't really know anybody. There are airplanes.

The system isn't set up to benefit doctors. (Or patients, sadly). The best you can hope to do is navigate it so that you find the trade offs you can live with. Much like any profession, I suppose.


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[Shikima]

I think I need to qualify my statement further about being institutionalized. During medical school and entering into the apprenticeship training programs labeled Internship, Residency and Fellowship, one becomes heavily invested into the institutional model. I will admit, when I transitioned from that to PP, I was scared. Now I realize the freedom both financially and how I want to practice.

 

[splik]

I'm curious as to why this is a point of contention with you regarding psych. I mean, there's a reason psych's psych and medicine is medicine, especially if you yourself chose psychiatry. I'm only a medical student, but reading your list implies you chose your specialty poorly.

I'm not sure what your point is - psychiatry is a medical speciality and psychiatrists are physicians first and foremost. If psychiatrists are unable to diagnose and manage very basic medical problems, or initate a workup of neurological or medical causes for psychiatric complanits it undermines the very basis of psychiatry as a medical specialty.

 

[nancysinatra]

But some judge somewhere has ordered sex offender treatment and therefore I have to give this guy a mental illness label so it can all get paid for. It's nuts.

This is a huge problem in psychiatry and it's one more reason I'm switching fields. I worked at a state hospital for nearly a year where all the patients were committed there by judges. Many of the patients were not mentally ill in the slightest. I was paid a lot to pretend that they were. There was a whole unit devoted to "treating" antisocial men and it was just a joke. State hospitals and sex offender programs are a throwback to the 1950s era of psychiatry, and even earlier. We don't learn about them in residency and I think that is absolutely by design. What I saw at that job made me even more annoyed than ever with this specialty.

At a previous job (in the same state) I once had a judge court order a patient to the psych ward in order to be provided with involuntary treatment for an unproven case of epilepsy. State law prohibits using a neurological diagnosis for an involuntary psychiatric commitment, but there is nothing in state law requiring judges to know the difference between neurology and psychiatry, and apparently this judge "felt" that the patient's refusal of seizure meds was a psychiatric problem, and we needed to "fix" it. What was especially upsetting about this situation is that the psych ward is actually a really bad place for a patient with seizures, since we can't intubate, and don't have IVs. That judge didn't have a medical license but he was allowed to practice medicine. I doubt the same is true in cardiology, surgery, or any other specialty. One more ding against psychiatry, if you ask me.

The APA and AAPL should be addressing the issue of how judges are able to tell us how to do our jobs, but they are not addressing that, and they won't be addressing that, because there is no money in it and they don't care.

 

[nancysinatra]

I'm curious as to why this is a point of contention with you regarding psych. I mean, there's a reason psych's psych and medicine is medicine, especially if you yourself chose psychiatry. I'm only a medical student, but reading your list implies you chose your specialty poorly.
Also, this is the first time i'm hearing about NP domination. Care to elaborate?

I did choose my specialty poorly. I wish I had gone into trauma surgery instead.

As for NPs, I currently work in a relatively economically depressed rural area in a state that claims to have a dire shortage of psychiatrists. NPs fill that gap. I've thought a lot about why this is the case and have concluded that people in this state just want pills to solve all of life's problems. They want pills for anger, pills for sleep, pills for their "moods," pills to make them like Walmart more (whenever patients tell me about panic attacks, they always seem to happen at Walmart) and pills to make them like their relatives more. Oh, and disability paperwork and paperwork for therapy animals. People want that filled out. Almost no one wants to go to therapy, and I don't blame them, because the options for that have all been dismantled in this part of the country. I feel bad for the patients, and I try to use my therapy skills to help them, but it's hard, because they come with the expectation that they can get a pill to solve everything. Many people do not meet DSM criteria for an Axis I condition, yet they make appointments and come back. I don't really know why except that life is hard for a lot of people. There is no DBT available and no inpatient treatment for Axis II problems. So it's a revolving door.

Otherwise I do not know why it would be the case that in, say, 1970, there was no shortage of psychiatrists (or so I assume), but now, in 2015, there is this huge shortage. The population hasn't grown that much. In 1970, people were put in institutions rather than receiving outpatient care, which was bad in its own way, but at least then, they had to be really mentally ill to end up in an institution. In this day and age we are treating people who aren't even necessarily mentally ill. So more providers are needed.

NPs are allowed to practice unsupervised in this state, and they absolutely dominate rural psychiatry. At least in rural areas they are far, far more common than MDs. I don't have numbers, but my observation is that this seems to be the case in not just psych but also primary care, and even in some IM subspecialties. I see a lot of polypharmacy with NP prescribing practices. No one seems to care, so I think this will just increase as time goes on.

 

[Achillees]

This is a huge problem in psychiatry and it's one more reason I'm switching fields. I worked at a state hospital for nearly a year where all the patients were committed there by judges. Many of the patients were not mentally ill in the slightest. I was paid a lot to pretend that they were. There was a whole unit devoted to "treating" antisocial men and it was just a joke. State hospitals and sex offender programs are a throwback to the 1950s era of psychiatry, and even earlier. We don't learn about them in residency and I think that is absolutely by design. What I saw at that job made me even more annoyed than ever with this specialty.

At a previous job (in the same state) I once had a judge court order a patient to the psych ward in order to be provided with involuntary treatment for an unproven case of epilepsy. State law prohibits using a neurological diagnosis for an involuntary psychiatric commitment, but there is nothing in state law requiring judges to know the difference between neurology and psychiatry, and apparently this judge "felt" that the patient's refusal of seizure meds was a psychiatric problem, and we needed to "fix" it. What was especially upsetting about this situation is that the psych ward is actually a really bad place for a patient with seizures, since we can't intubate, and don't have IVs. That judge didn't have a medical license but he was allowed to practice medicine. I doubt the same is true in cardiology, surgery, or any other specialty. One more ding against psychiatry, if you ask me.

The APA and AAPL should be addressing the issue of how judges are able to tell us how to do our jobs, but they are not addressing that, and they won't be addressing that, because there is no money in it and they don't care.

Well that's incredibly disheartening. Is this avoidable by doing majority/all outpatient psychiatry?

I did choose my specialty poorly. I wish I had gone into trauma surgery instead.

As for NPs, I currently work in a relatively economically depressed rural area in a state that claims to have a dire shortage of psychiatrists. NPs fill that gap. I've thought a lot about why this is the case and have concluded that people in this state just want pills to solve all of life's problems. They want pills for anger, pills for sleep, pills for their "moods," pills to make them like Walmart more (whenever patients tell me about panic attacks, they always seem to happen at Walmart) and pills to make them like their relatives more. Oh, and disability paperwork and paperwork for therapy animals. People want that filled out. Almost no one wants to go to therapy, and I don't blame them, because the options for that have all been dismantled in this part of the country. I feel bad for the patients, and I try to use my therapy skills to help them, but it's hard, because they come with the expectation that they can get a pill to solve everything. Many people do not meet DSM criteria for an Axis I condition, yet they make appointments and come back. I don't really know why except that life is hard for a lot of people. There is no DBT available and no inpatient treatment for Axis II problems. So it's a revolving door.

Otherwise I do not know why it would be the case that in, say, 1970, there was no shortage of psychiatrists (or so I assume), but now, in 2015, there is this huge shortage. The population hasn't grown that much. In 1970, people were put in institutions rather than receiving outpatient care, which was bad in its own way, but at least then, they had to be really mentally ill to end up in an institution. In this day and age we are treating people who aren't even necessarily mentally ill. So more providers are needed.

NPs are allowed to practice unsupervised in this state, and they absolutely dominate rural psychiatry. At least in rural areas they are far, far more common than MDs. I don't have numbers, but my observation is that this seems to be the case in not just psych but also primary care, and even in some IM subspecialties. I see a lot of polypharmacy with NP prescribing practices. No one seems to care, so I think this will just increase as time goes on.

You paint a very dismal future for Psychiatry, but thank you for your honesty. All anecdotes are helpful.

 

[Achillees]

I'm not sure what your point is - psychiatry is a medical speciality and psychiatrists are physicians first and foremost. If psychiatrists are unable to diagnose and manage very basic medical problems, or initate a workup of neurological or medical causes for psychiatric complanits it undermines the very basis of psychiatry as a medical specialty.

My response was in the context of the whole list. "PHQ9...patients who wont stop talking...having to tell strangers what I do" etc. OP themselves said they chose their specialty poorly and should've been a trauma surgeon. I'm well aware we're a medical specialty. Family would've been my second choice.

 

[smalltownpsych]

I did choose my specialty poorly. I wish I had gone into trauma surgery instead.

As for NPs, I currently work in a relatively economically depressed rural area in a state that claims to have a dire shortage of psychiatrists. NPs fill that gap. I've thought a lot about why this is the case and have concluded that people in this state just want pills to solve all of life's problems. They want pills for anger, pills for sleep, pills for their "moods," pills to make them like Walmart more (whenever patients tell me about panic attacks, they always seem to happen at Walmart) and pills to make them like their relatives more. Oh, and disability paperwork and paperwork for therapy animals. People want that filled out. Almost no one wants to go to therapy, and I don't blame them, because the options for that have all been dismantled in this part of the country. I feel bad for the patients, and I try to use my therapy skills to help them, but it's hard, because they come with the expectation that they can get a pill to solve everything. Many people do not meet DSM criteria for an Axis I condition, yet they make appointments and come back. I don't really know why except that life is hard for a lot of people. There is no DBT available and no inpatient treatment for Axis II problems. So it's a revolving door.

Otherwise I do not know why it would be the case that in, say, 1970, there was no shortage of psychiatrists (or so I assume), but now, in 2015, there is this huge shortage. The population hasn't grown that much. In 1970, people were put in institutions rather than receiving outpatient care, which was bad in its own way, but at least then, they had to be really mentally ill to end up in an institution. In this day and age we are treating people who aren't even necessarily mentally ill. So more providers are needed.

NPs are allowed to practice unsupervised in this state, and they absolutely dominate rural psychiatry. At least in rural areas they are far, far more common than MDs. I don't have numbers, but my observation is that this seems to be the case in not just psych but also primary care, and even in some IM subspecialties. I see a lot of polypharmacy with NP prescribing practices. No one seems to care, so I think this will just increase as time goes on.

I don't know if you really did choose the wrong specialty. Your frustration with the problems in the field and astute descriptions of those problems would argue otherwise. 😎

I would say that we need more psychiatrists and psychologists who are frustrated with the way the system doesn't work and with society's views on mental health. I tell patients almost every day that a medication will not fix them and sometimes will make it worse. Some of them don't like to hear this, but I have to counter the lies that they are hearing everyday and telling themselves. Effective psychotropic medications are both a gift of psychiatry and a curse. We all know the poster child for the medications and so do many of our patients, too bad they tend to be the minority and also once their depression has remitted they take their medication at the same dose for years at a time and we forget all about them. Meanwhile, the parade of people in and out of the mental health system with substance abuse problems looking for a magic pill continues. If we didn't have to deal with them every day, then we would have more resources to deal with the real patients who are often the victims of those same substance abusers.

 

[Shikima]

I don't know if you really did choose the wrong specialty. Your frustration with the problems in the field and astute descriptions of those problems would argue otherwise. 😎

I would say that we need more psychiatrists and psychologists who are frustrated with the way the system doesn't work and with society's views on mental health. I tell patients almost every day that a medication will not fix them and sometimes will make it worse. Some of them don't like to hear this, but I have to counter the lies that they are hearing everyday and telling themselves. Effective psychotropic medications are both a gift of psychiatry and a curse. We all know the poster child for the medications and so do many of our patients, too bad they tend to be the minority and also once their depression has remitted they take their medication at the same dose for years at a time and we forget all about them. Meanwhile, the parade of people in and out of the mental health system with substance abuse problems looking for a magic pill continues. If we didn't have to deal with them every day, then we would have more resources to deal with the real patients who are often the victims of those same substance abusers.

The age old question, "If you don't want to help yourself, why are you here then?"

Further demonstrated by - How many psychiatrists does it take to change a lightbulb? None unless the lightbulb wants to change.

 

[Rogue Penguin]

I've thought a lot about why this is the case and have concluded that people in this state just want pills to solve all of life's problems. They want pills for anger... and pills to make them like their relatives more.

I sometimes wonder where or how to draw the line between treating depression and medicating people into complacency. For example, someone I know is really unhappy with her relationship with their husband. And rightly so, their relationship is exploitative and abusive towards her. But instead of doing something to make her life better (getting a divorce, going to couple's therapy, trying to make new friends or spend more time with other loved ones, exercise) she just keeps going up on her dose of anti-depressants because she's miserable. At this point, she's maxed out on Zoloft and Wellbutrin. (these meds are prescribed and managed by a family medicine doc.) I have no doubt that she truly has symptoms of depression, she needs to change her life not take meds until she's able to suffer through it. Clearly, she needs psychotherapy but she's unwilling to seek any out. Due to where she lives, she'd probably have to drive 30-60 minutes to find someone to do the therapy. I guess this just illustrates why therapy and access to it are important components of treatment?

I'm not a doctor yet, but I imagine that patients lacking access to the resources they need to get better will be one of the worst parts for me.

Also someone needs to do something about how crappy access to care is in Kentucky.

 

[heartsink]

NPs are allowed to practice unsupervised in this state, and they absolutely dominate rural psychiatry. At least in rural areas they are far, far more common than MDs. I don't have numbers, but my observation is that this seems to be the case in not just psych but also primary care, and even in some IM subspecialties. I see a lot of polypharmacy with NP prescribing practices. No one seems to care, so I think this will just increase as time goes on.

Not to derail the thread but this is really discouraging to hear. Everywhere else on this sub-forum I hear optimism that not only will physicians continue to carry the day in psychiatry over NPs, but that there are even more jobs in rural areas and the midwest where the shortage of psychiatrists is even sharper. I recognize this is anecdotal, but its still telling of a different picture in at least part of the country.

 

[PistolPete]

I really hate this whole issue of "parity diagnoses." No other field, as far as I know, has to deal with this.

But for psychiatry, we have to put a diagnosis from a certain list "otherwise we won't get paid." So if the true issue is a substance-inducted mood disorder, I can't put that as the first diagnosis and be done with it (except at the VA), but have to list some other closely-related but not 100% true diagnosis so that "we can get paid." Ugh.

 

[sunlioness]

Not to derail the thread but this is really discouraging to hear. Everywhere else on this sub-forum I hear optimism that not only will physicians continue to carry the day in psychiatry over NPs, but that there are even more jobs in rural areas and the midwest where the shortage of psychiatrists is even sharper. I recognize this is anecdotal, but its still telling of a different picture in at least part of the country.

Um, there are. NPs aren't pushing psychiatrists out. They're filling in the void that the dearth of psychiatrists has left for them. As a psychiatrist, you can pretty much find a job wherever you want one especially in a rural craphole.


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